Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline?
Both the yes and no arguments are made persuasively, and I found myself on the fence after reading them, perhaps leaning ever-so-slightly toward the “no” side (optimist that I am). Sure, times are tough, but we’ve got the Right Stuff and we’ve bounced up from the mat before.

Then I considered the political fracas over Don Berwick’s appointment as director of the Centers for Medicare & Medicaid Services (CMS), and decided to change my vote, sadly. Yes, America is in decline, and this pitiful circus is Exhibit A.

Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.

President Obama’s selection of Berwick to lead CMS last year was inspired. In the face of unassailable evidence of spotty quality and safety, unjustifiable variations in care, and impending insolvency, Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency. There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.

But Berwick’s nomination ran into the buzz saw of Red and Blue politics, with Republicans holding his nomination hostage to their larger concerns about the Affordable Care Act. In the ludicrous debate that ultimately culminated in Obama’s recess appointment of Berwick, the central argument against his nomination was that he had once – gasp – praised the UK’s National Health Service. Interestingly, without mentioning Berwick by name, Fareed Zakaria pointed to this very issue to bolster his “decline” argument in Time:

A crucial aspect of beginning to turn things around would be for the U.S. to make an honest accounting of where it stands and what it can learn from other countries. [But] any politician who dares suggest that the U.S. can learn from – let alone copy – other countries is likely to be denounced instantly. If someone points out that Europe gets better health care at half the cost, that’s dangerously socialist thinking.

I’ve argued that President Obama was right to use his recess appointment power to install Berwick as CMS director, and hoped – naively perhaps – that Don would win over his critics by the time his appointment expired in December 2011. And, in his eight months in the role, Berwick has done a terrific job. As always, his speeches on healthcare reform have been articulate and thought provoking (though one can see a heavy bureaucratic hand tamping down Don’s characteristic flair and penchant for provocativeness). He has appointed excellent people to key leadership positions, fleshed out some of the new CMS programs such as Value-based Purchasing and the Innovations Center, and will announce a major initiative in patient safety in the near future. Impressively, Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back: doubt about his own future at CMS, uncertainty about the fate of the Affordable Care Act, and an unrelentingly hostile reception by the Republicans in Congress.

But my hopes were dashed by this week’s statement by Sen. Max Baucus (D-Montana) that Berwick’s is simply not confirmable by the Senate. This announcement followed a letter sent to the White House last week by 42 GOP senators, who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.” If the White House pulls the plug, he is likely to be replaced by his deputy, Marilyn Tavenner, a nurse administrator who ran two suburban hospitals for HCA and was Virginia’s Secretary of Health. The American Enterprise Institute blogger Joseph Antos praised her, sort of:

Tavenner has a reputation for making the trains run on time…. More importantly, [she] would not act as if she has a mandate to upend the health system, because she doesn’t.

In all likelihood, Tavenner would sail through her confirmation hearings, precisely because she won’t cause a stir.

But we need a stir!

From the moment of his nomination, Berwick’s plight has been a sad spectacle. I was particularly disheartened by the way he was treated during his testimony before the House Ways and Means Committee. It is too long and painful to watch the whole thing; if you’ve taken your Compazine, try a 5 minute stretch that begins precisely an hour into the testimony, as Representatives Davis and Reichert bait Berwick with a combination of hyperbole and rhetorical foolishness (“I’m not interested in an academic salon answer…”) that would make a middle school playground argument seem positively Shakespearean.

In the face of this kind of nonsense, I know of several superb physician-leaders who were offered positions in CMS – for roles that should have been once-in-a-lifetime opportunities to shape national policy – but turned them down. “Who needs this?” one told me. And they’re right.

The smart money is that the White House will fold on the Berwick appointment. The legendary Lucian Leape emailed many of Don’s colleagues yesterday, including me, asking that we sign on to a letter to the president in support of Berwick. Lucian wrote:

Watching the hearings and reading the statements being issued by the Republicans on this matter has been both disappointing and disgusting as we see our eminently qualified colleague disparaged by those who have no appreciation for what he has done and can do for our health care system.

I gladly signed this letter, and I hope you’ll do what you can to turn this around. Please contact the White House, your senators and representatives, and the media, and tell them that Don Berwick is the best hope we have to improve our healthcare system. Tell them that the Senate should hold hearings on his appointment, letting the chips fall where they may. Tell them to start acting like grown-ups.

If this good and great man is thrown under the bus, you’ll have all the evidence you need that our society is, in fact, in decline. Let’s not let this happen without a fight.

The fact remains CMS is the largest payor in the world and he has ZERO qualification to run such an organization. All of his postive traits qualify him to manage a division of Medicare engaged in the actions he has experience in. Its not surprising you anti business liberals have no clue how successful orgainizations are managed, in your world efficency and success doesn’t matter you just raise taxes more.

Berwick belongs in some department someplace working on quality and saftey issues. Before Medciare goes spending any more money to improve quality and increase cost even further they need to reign in their fraud and inefficiences, something Berwick doesn’t even have a single day of experience doing.

Nate,
I respectfully disagree. You underestimate the ability of Don Berwick. I cannot think of a person more qualified for the position. As per the IOM report, poor quality, inefficiencies and ineffective management of population health are all drivers of rising cost of healthcare.

BobbyG not that you need any help looking like an idiot but I make my living competing with AHIP members. When I succeed they lose. I get business by pointing out AHIP member lack of efficency. No one in my industry is making 8 figure compensation packages.

Thanks for another dumb ass comment, 3 for 3 making quit the name for yourself. I guess if you can’t debate facts or discuss matters inteligently then you resort to commenting like you do.

You raise a good point about what are exactly the qualifications for the job. But the point I hear Bob making is that 1) we should absolutely hear these out in confirmation hearings and 2) to disparage a man that has so passionately dedicated his life to helping patients not the status quo, points to the politics as usual. And that is sad because we have a crisis of the status quo. Unfortunately I believe the way the White House handled his initial appointment just added to this.

To your point Nate about whether he is capable of effectively managing such a huge organization, I would look at more broadly in terms of the make up of the senior leadership team. Having helped organization with role definition it is not uncommon to place the visionary leader at the top of the organization to set the pace and culture. The COO or Deputy in this case role is then to make sure the train run on time but on the right tracks headed in the right direction. High tech companies use this approach very successfully. I think that is the problem with healthcare we have to many manages and not enough leaders. We have incremental change.

Regardless of what we think of his beliefs, I would encourage the Senate to give Dr. Berwick his due course and I will reach out to my Senators. Bob appropriately identified the harm in the buzz saw of red and blue politics. If that persists those with innovative ideas will clearly not want to raise their voices.

As Albert Einstein said the “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Today that statement rings so true.

Bob’s post was very anti-republican and inflamatory. I don’t disagree with your two points but lets review them.

1. Confirmation hearing, I agree 100% he should have one, why hasn’t he? Democrats control the senate and would be the ones to schedule such a hearing. The ONLY reason there has not been a hearing is becuase Democrats won’t schedule it. Personally I think even if someone gets a recess appointment they should first have to have a hearing. Nothing in this point justifies Bob’s attack on the right.

2. Since Bork this is how things are, I don’t agree it is bad. His supporters want to hold him up as a savior. People like Maggie Mahar created an entirly new religion to worship him. If you disagree with someone that puts him on a pedastool you can’t do so by just saying I disagree. As aggresivly as they anoint him you must counter.

I think visionary leaders are great for small and start up firms, in those cases the size is manageable enough they can effect the business. When you get to be the size of GE or CMS visionaries are not effective. What is killing Medicare? It’s not lack of vision it’s failure to manage day to day operations. They need to stop losing 10% of every dollar to fraud. They need to perform their core functions better. This is not visionary work, this is nuts and bolts roll up the sleeves hard work. This is why founders and visionaries are almost always pushed aside when corporations get to a certain size.

There is still a role for visionaries, its just not at the top.

If Bob cared one bit about getting a hearing he wouldn’t attack Republicans in making his argument for Berwick, and he would get his facts correct. Republicans can only hold up his appointment, his nomination is solely in the hands of Obama and his confirmation hearing in the hands of Democrats, for some reason those facts go left out of his post.

My biggest gripe with his post;

“who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.”

What is disingenuous abou it? Bob can’t argue this point, its true he is not qualified and doesn’t have the experience for this aspect so he tries to write off the entire argument as disingenuous. You can argue how much of CMS is a payor and how much is a health system or care provider but to claim it is a disingenuous argument is just dishonest. You can’t complain about the partisian aspect of it when your in the middle of a political diatribe.

Gee, you read this and the adage “if it’s too good to be true, it probably isn’t” comes to mind.

“Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.”

“There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.”

And my favorite from the post, ” Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back…”

Gee, Robert Wachter, who needs God when you have Don Berwick. Are you his PR guy, or just have so much invested in PPACA surviving that had Obama nominated Dagwood Bumstead for this post he would still get the same radioactive glowing praise as above?

You read posts like this and have to wonder who the authors think the audience is. Oh, I forgot, the Obamacare Tabernacal Choir!!!

I do not understand where Nate Ogden comes from when he says Dr. Berwick has no qualifications for managing CMS. It seems to me Dr. Berwick understands very well the principles of affordability, transparency, accountability, availability and evidence based that must underly a responsible health care system. The only thing I left out is universality since that is still not on the table. To implement these principles requires someone with vision who is willing to stir things up and that sounds like something many physicians who are benefitting from the present system and building there partnership cardiac and orthopedic hospitals do not wish to consider. We all need to know where the money is going and that means public disclosure of cost per physician per patient per year of all public funded and subsidized health care.

If CMS was a health care system then you might be right. CMS is a payor or healthcare plan. CMS doesn’t deliver healthcare they purchase it from healthcare systems. Berwick would be a better fit to manage one of those systems. he is a terrible fit and has no experience managing any plans.

”
“I think visionary leaders are great for small and start up firms, in those cases the size is manageable enough they can effect the business. When you get to be the size of GE or CMS visionaries are not effective”

Cheney went from a govt job to running Haliburton. He worked as a physician, he worked in administrative positions in medical system(s) and runs his own organization where he also studies and reports on health care management. He knows the system from the bottom up. He has studied and critiqued the system for years. He has made contributions through the system to improve quality. I think that he offers a good balance of training and experience. I say give him some number crunchers and let him work.

We are at the point, or close to it, where we need some people with ideas and willing to take some risks to try to fix things. Another caretaker type, while not the end of the world, would be less preferable, but easy to find if he leaves.

You raise good points and I think we need to debate the necessary leadership talent needed at CMS as shown by Steve’s addition to the dialogue. It is a discussion worth having and I am glad you agree on the need for a hearing. I also took away from Bob’s note that it was the White House’s decision whether to proceed or not with Baucus providing more justification to fold. Yes Bob’s note was partisan as he only noted at one point that both sides engage in this activity (the buzz saw of blue-red politics) but the point is this. I see this image of the little kid in the playground who actually might have a brain and something to offer to his fellow students but there are these ridiculous bullies who shout and yell and stamp out anything remotely innovative, different or intelligent. That is our culture. We all own it and we will all be looking at failing healthcare (i.e. country) if we don’t do something about it. And shame on all parties if they don’t hear Berwick out…. the bullies would have won on both sides.

Most importantly Bob’s blog prompted me to write my Senators (Kohl/Johnson) to ask for a hearing. If his goal was to prompt this type of behavior, l believe it was effective.

Over the past two and a half decades Dr. Berwick and IHI have helped hospitals, homecare agencies, physician practices, and the ever important C-suite to improve their cost-effectiveness and quality of care.

Isn’t that our concern… escalating costs and inconsistent quality?

An earlier post suggested that Berwick lacks the experience of the heads of health plans such as Aetna. While he did not head a healthplan, this comment overlooked the fact that the leading CEOs routinely have sought out Dr. Berwick’s advice and guidance. Could it be that the folks you admire would suggest he has the credentials? It’s a question worth asking,

But what I find most troubling is that we have not been given an opportunity to hear directly from Dr. Berwick through the confirmation hearing process. And last–while easy to be a naysayer–I haven’t heard anyone suggesting a more qualified candidate. Why is that? Could it be that some people just want to make it impossible for CMS to function? Given the challenges of rising healthcare costs within the context of our current economy such hamstringing would be un-American.

There are different ways to approach the CMS job and different attributes that can make one suitable for the job. One view is to have an effective and experienced administrator, one who has run large organizations. The other, equally valid, is to have someone who is a competent manager but who serves more as a thought leader to help move the agency to a new place, one that helps it get ready to serve the future needs of the country as well as the current legislative requirements. Clearly Don is more in the second category than the first.

I would argue that the second role is more important for the US right now. We have a health care system that has many good attributes but clearly needs improvement with regard to the cost, quality, and equity of care that is delivered. Don’s main “crime” is that he talks out loud and directly about that. But, he is just as quick to praise the US system where it deserves praise.

I am with Dr. Wachter, in that I think the country needs more of the kind of direct talk Don offers, not to denigrate ourselves, but to help us deliver the kind of care we all say we stand for. The political environment in DC, though, makes it hard to get confirmation for someone like Don. That is a shame. He has shown, through prior work, that his goal is simply to help make a better delivery system. His comments about other countries, as someone has noted above, do not ignore the flaws in those systems. He is simply asking us to be modest and see if we can learn good things from them. Likewise, he asks them to do the same — from us — when he talks to audiences there.

It is no surprise that other highly competent leaders from the medical community have turned down the Administration when they have been contacted regarding this job. They are already doing good things in their own hospitals or health systems, and they understand how hard it is to make progress at CMS, and how they will likely be personally attacked for their views in the DC cauldron.

I don’t expect this to change. What it suggests, though, is that the medical system in the US will have to advance by dint of hard work, innovation, process improvement, transparency, and patient involvement at the local level. CMS is more likely to be a follower than a leader without someone like Don Berwick at the helm. Let’s hope, though, that the next administrator is able to draw lessons from the field and use them to the public good at the agency.

Berwick has failed the citizens in the United States because he promotes the EMR and CPOE as the savior of safety, when those instruments of care are intrinsically unsafe. To make matters worse, they have never been evaluated for safety, efficacy, and usability. He has gone along with the sham the HIT vendors have perpetrated on the US. Dandy Don would be welcomed if he demanded accountability of the devices that are directing the care of the patients he cares so much about.

If Paul Levy is promoting transparency, let’s hear about the debacles and more simply the errors of computerized care at his hospital. He is not spouting that overall outcomes are better at BIDMC nor are his costs down. Bob ought to do the same from UCSF. What actually did happen with GE Centricity, Bob? How many deaths were there?

Paul, tell us about the use of robots and the volume of prostate surgery at BIDMC, and Bob, you do the same at UCSF.

Why do you feel it necessary to attack Bob and me for the work going on in our hospitals (or, in my case, my former hospital)? I don’t think either of us has ever claimed perfection. I do think we have both claimed that we have learned a lot about quality, safety, and process improvement over the years; and that we are always happy to share what we have learned. Indeed, both of our blogs are full of examples of both what has worked and what has not.

And why do you use language like “Dandy Don” in such an important discussion. Can’t we stick to the merits of the issue without ad hominem attacks? I have never heard Don talk about computer systems as the “savior of safety.” Indeed, Don’s point is often that we need to understand the work flow in clinical settings, improve that work flow, and then have computer systems that support it.

Bob’s point in this article had as much to do about the quality of the discourse in DC as anything. I am afraid that you have inadvertently shown an example of what is not so helpful as we all try to figure out what might make the US system better and stronger.

I have no doubt that Dr. Berwick would be an appropriate candidate to lead CMS, but I have no doubt that there are probably several dozen others that would be as appropriate.
What is happening now in DC is not personal, it’s business, the business of obstructionist politics on both sides. If we really want a talented person to run CMS, it will have to be someone pre-vetted by both sides, someone who is equally liked and disliked by both sides. Does this imply compromise on quality for this clearly political appointment? Probably not, since I do believe there should be quite a few interchangeable folks that could be successful. If we argue that Dr. Berwick is the one and only, then we really are in a world of hurt in this country.
So as frustrating and painful as this may be for some of us, let’s get on with filling that crucial role at CMS as soon as possible.

It isgood to be reminded that people who actually know Berwick– and understand the problems in our health care system– recognize what a loss this is.

As you suggest, the fact Congress rejected Berwick says something about where this country is at this point in time. Berwick is too honest, and too intelligent to be accepted by Washington. And very few people of his calliber are willing to serve in a government ruled by the politics of hate.

Maggie Mahar has it right about everything except that ‘Congress rejected Berwick.’
That hasn’t formally happened yet. I hope that enough of those mistakenly opposed to his confirmation change their minds to vote for something good for America—the confirmation of Donald Berwick as the CMS head.

Same people claiming Berwick is the best person for CMS and the country would be terrible if he doesn’t get the job said the same thing about Obama and look at the joke he turned out to be. Unqualified, unable to perform his duties, unless you call him the golfer-in-chief, and scared to actually make any decisions. Obama is a perfect example of someone put into a job they don’t have the qualifications for, Berwick is no more qualified to run CMS then Obama was to be President.

While Obama was hyped up to be more than he was, I still prefer him over McCain/Palin. Obviously, this is a political preference and I don’t intend to convince you.

On the other hand, Don Berwick is revered among health care professionals who have worked in health care improvement–which involves improving efficiency, lowering costs, improving quality, and increasing accessibility of health care services. He has NEVER played in politics. Perhaps there are other people who have qualifications to do this job, but no one is as good for the job as Dr. Berwick; he is a visionary leader in health care improvement and has done more for our understanding of systems based changes (taken directly from businesses, e.g. the airline industry, the Toyota production line, methods like Six Sigma) than anyone else. And if some think that his singularity is sad for this country, then it is sad.

The idea that a business executive would be better is also misleading. Sure, CMS is a payor, but it is far more than that. CMS is not out to undercut competitors; in fact, politicians have repeatedly and explicitly forbade it to negotiate prices (for drugs, for example) like a normal payor, for fear of hurting the private markets. Cigna can make plans that squeeze out the sicker population to raise their bottom line. CMS can’t.

As for fraud, it’s unfortunate that people try to defraud CMS. Unfortunately, CMS is the easiest, largest target to defraud. Fraud usually takes the form of something like this: open up shop offering info on “free” Medicare-paid health care equipment, like wheelchairs, scooters, or diabetic shoes. Get Medicare enrollees to give you their information so you can “check if they are covered”. Charge Medicare for the equipment that the enrollee did not receive.

Medicare fraud is much greater than Medicaid fraud, and the reason is most likely because older, sicker people are easy to defraud. The elderly are less likely to check and ensure that their provision of benefit receipts from CMS are accurate (which outline what has been paid on their behalf) and are easier targets of identity theft. I get the same documents from my private insurer, outlining the claims that have been made on my behalf. But as a young professional, I check to make sure everything is correct and I’ll be sure to alert my insurer if they aren’t correct (because I’ll eventually pay for that in premiums). Would my grandma be up to doing the same? No way! The response to this unfortunate situation is either A) make it harder to be reimbursed by CMS (such a move is opposed by hospitals and providers) or B) police fraud like the mafia and give the law enforcement department of HHS more money to do this.

Finally, the NHS is an incredible system. We all gripe about our own system, but very few Brits come to the US for healthcare to escape the “awful” NHS. It is also a system undergoing changes and challenges of its own, but the British government spends a fraction of what we spend in the US per capita and achieves universal health coverage where no one is turned away. Sure, perhaps your elective surgeries take longer, but if you have the money, you can go to a private hospital and pay out of pocket. You can do that in any country, even in the US. Your health insurance won’t pay for that CT scan? Pay $1000 yourself. However, if you hope to be subsidized by the government or insurance, then you may have to wait. That seems fair to me.

What does this have to do with CMS? CMS is not a health care provider, they are a health care payor. He has no experience or qualifications to run a health care payor.

” Sure, CMS is a payor,”

a payor? They are the largest payor in the world. Its also their primary and most important duty. Your not talking about some side business or related company that generates a couple percent revenue, payor is the big one, that is the one thing they need to do right before all else.

“politicians have repeatedly and explicitly forbade it to negotiate prices”

Correct becuase they dictate prices. When Medicare was originally passed they promised to negotiate fair prices for doctors but that got in the way so they just repealled that part of the law and telling providers what they would be paid. Much easier when you don’t allow the other side a say. How long till they do the same with Rx?

“Cigna can make plans that squeeze out the sicker population to raise their bottom line. CMS can’t.”

While technically true your point is wrong. Medicare waanted to push people off on private insurance so they just passed a law saying private insurance is primary. That wasn’t enough so they made it illegal to incentivse people to go on Medicare. Don’t forget the second M, the whole reason States and Feds require 26-30 years old kids be covered on parents policy is to get sick Medicaid patients off the rolls. CMS has been far more effective in pushing off bad risk then any private insurer.

What is Berwick’s qualification to address fraud? He has none. Wouldn’t the CEO of a major insurer that has dealth with issues like that for 10-20 years be better qualified?

“but the British government spends a fraction of what we spend in the US per capita and achieves universal health coverage where no one is turned away.”

THis is a lie. Try getting expensive cancer drugs. Try getting no emergency surgery, putting someone on a 12 month waiting list is just the same as turning them away. Try having a 20 week premature baby and being told they won’t treat the baby becuase they are to young. They turn away babies to die every week.

It would be nice for a change if people pimping the NHS actually knew how the NHS worked, Berwick included. Either that or your all just rank dishonest and hide the flaws for your political gain. Personally I hope its ignorance not politics.

I said at the time (and posted it, as I recall) that the decision to side-step confirmation with a recess appointment would do a long-term disservice to Mr. Berwick. It was a short-term gain, but came at a cost later. It would have been better to hold the hearings when the appointment was first proposed, let Mr. Berwick answer any criticism in public, and then vote.

Obama threw Berwick under the bus instead of letting him have his day in front of the Senate. The Senate Democratic leadership (quite an oxymoron) has done nothing to help. Harry Reid wouldn’t know leadership if it smacked him across the face.

On the other hand, a hearing likely would become a political circus, fueled by national media that are either too afraid or too lazy to look beyond the superficial mudslinging. As a journalist myself, I’m ashamed that the national media was so bad in reporting about health reform that they’re complicit in the public’s thinking that health insurance is synonymous with health care.

I believe that Mr. Berwick would most likely have been confirmed had he been able to have a hearing. In the end, most of the time congress will defer to the chief executive on matters relating to picking their “team”.

We frequently accept crossposts from smaller blogs and major U.S. and International publications. You'll need syndication rights. Email a link to your submission.

WHAT WE'RE LOOKING FOR

Op-eds. Crossposts. Columns. Great ideas for improving the health care system. Pitches for healthcare-focused startups and business.Write ups of original research. Reviews of new healthcare products and startups. Data-driven analysis of health care trends. Policy proposals. E-mail us a copy of your piece in the body of your email or as a Google Doc. No phone calls please!

THCB PRESS

Healthcare focused e-books and videos for distribution via THCB and other channels like Amazon and Smashwords. Want to get involved? Send us a note telling us what you have in mind.
Proposals should be no more than one page in length.

HEALTH SYSTEM $#@!!!
If you've healthcare professional or consumer and have had a recent experience with the U.S. health care system, either for good or bad, that you want the world to know about, tell us about it. Have a good health care story you think we should know about? Send story ideas and tips to editor@thehealthcareblog.com.